1. 1 TRAINING IN PUBLIC HEALTH CARE FACILITIES FOR HEALTH CARE WASTE MANAGEMENT Dr. A Swart - TWR Ms. N Coulson – HDA Ms. D Nteo - TWR

2. 2 OVERVIEW  Introduction  Identifying training needs  Use of qualitative research methods  Results from the qualitative research relevant to the design of the training intervention  Design of the capacity building programme  Evaluation results from the cascade training programme  Training programme for health care waste officers  Conclusion

3. 3 INTRODUCTION  Training as an essential component of health care waste management (HCWM)  Training in HCWM for public sector in Gauteng  Gauteng Sustainable Health Care Waste Management project  Research at two pilot sites: –Leratong Hospital –Itireleng Clinic

4. 4 IDENTIFYING TRAINING NEEDS  Performance discrepancy analysis  “Capacity” in terms of “performance”  For HCWM, three commonly areas of discrepancy (gaps) are: –knowledge gaps; –skills gaps; and –attitude gaps

5. 5 Training needs cont.  Other areas to impact on the delivery of HCWM systems include: –inter-staff relations; –worst case scenarios; –technology gaps; –policy and procedures gaps; and –organisational, management and supervisory gaps.

6. 6 QUALITATIVE RESEARCH METHODS  Focus group interviews at Leratong and Itireleng  More than 90 health workers including –two focus groups with senior and professional nurses; –two focus groups with auxiliary and enrolled nurses; –one focus group with doctors; and –three focus groups with general assistants and ward helpers.

7. 7 PURPOSE OF FOCUS GROUPS  Explore the range of factors that impact on the behaviour and practices of staff  Explore the knowledge of staff about HCWM  Explore the attitudes to HCWM  Understand the roles and responsibilities in HCWM

8. 8 RESULTS FROM QUALITATIVE COMPONENT  Knowledge levels about HCWM improved down the traditional health worker hierarchy  Knowledge levels about segregation and hazards appeared good; re-enforcement required  Health workers felt unappreciated in relation to HCWM

9. 9  There is a level of poor practice in HCWM that is related to negligence, probably linked to low morale of health workers in the public sector  Multidisciplinary training is important to overcome communication barriers  Doctors believe that they do not have a role to play in HCWM

10. 10 DESIGN OF THE CAPACITY BUILDING PROGRAMME  Approach to capacity building had seven elements of which training was one part  Capacity programme complemented introduction of new equipment and addressed other important issues  Training was an integrated component of broader strategy

11. 11 Capacity building programme involved: 1.Code of Practice (new policy and procedures) 2.Improved monitoring and reporting through OHS committee 3.Introduction of dedicated Health Care Waste Officer and an Assistant 4.Knowledge, attitudes and skills training 5.Awareness activities 6.On the job skills coaching 7.Evaluation of capacity building activities

12. 12 CASCADE TRAINING PROGRAMME  Primary approach to knowledge, attitudes and skills training at pilot sites was a “train the trainer” approach  Cascade method of training – reach maximum number of people within short period of time  Supervisors trained to teach own staff  Information largely generic; multidisciplinary training where possible

13. 13  Supervisors received teaching pack, including: –three teaching posters; –teaching notes to reinforce main information to be taught; and –two interactive teaching exercises, to be completed on the wards and in departments.

14. 14  Key teaching topic reinforced - all health workers are members of the “waste team”, and has responsibility to teach and coach others  Teaching topics organised into three teaching posters supported by teaching notes  Supervisors introduced to teaching pack; train the trainer session lasting 2.5 hours  Supervisors to train multidisciplinary groups of staff, using one, maximum two teaching posters at a time

15. 15 Performance gap NursesDoctors General Assistants KNOW- LEDGE - HCWM equipment system - Segregation - Recycling - Procedures - Monitoring and enforcement - HCWM equipment system - Segregation - Recycling - Procedures - OHS reporting -Monitoring and enforcement - HCWM equipment system - Segregation - Recycling - Procedures - OHS reporting - Monitoring and enforcement Teaching topics to address the knowledge, attitude and skill gaps for nurses, doctors and general assistants at the pilot sites

16. 16 Performance gap NursesDoctors General Assistants ATTITUDES - Protection of OHS - Care of the environment - Communica- tion with seniors about waste tion with seniors about waste - Part of a team - Protection of OHS - Care of the environment - Communica- tion with nurses and general assistants about waste - Part of a team - Protection of OHS - Care of the environment - Communica- tion with medical staff about waste - Part of a team

17. 17 Performance gap NursesDoctors General Assistants SKILLS - Use of new sharp containers - Seal liners - Proper use and placing of coloured liners - Segregate all waste correctly - Coach other staff - Use monitoring and reporting system - Use of new sharp containers - Segregate all waste correctly - Use monitoring and reporting system - Coach other staff - Seal liners - Use protective clothing correctly - Proper use and placing of coloured liners -Load internal trolley - Unload internal trolley into 770 L bins - Coach staff - Use of chemicals

18. 18 CAPACITY BUILDING RESULTS  LERATONG 65 supervisors trained as trainers 24 doctors 41 general assistants OHS committee – 2.5 days of training  ITIRELENG 7 supervisors trained as trainers 8 general assistants/ ward helpers 14 nursing staff 2 social workers/health promoter

19. 19  91% of sample in follow-on study had been trained about the new waste system  73% found training very useful; 24% useful and 3% not useful  51% would like further training; 49% would not like further training

20. 20 KNOWLEDGE  BASELINE 85% medical waste is put in red liners 55% general waste goes to landfill 54% cardboard boxes go for recycling  FOLLOW ON 88% medical waste is put in red containers 77% general waste goes to landfill 73% cardboard boxes go for recycling

21. 21 SEGREGATION  Always segregate waste correctly – 68%  Sometimes segregate waste correctly – 20%  Training helps segregation – 80%  Well positioned containers – 53%  Good supervision – 46%

22. 22 TRAINING PROGRAMME – HEALTH CARE WASTE OFFICERS  Designation of HCW officers a component of capacity building programme  Recommended that HCW Officer and assistants be appointed at larger public health facilities  Designated responsibility for nurse, infection control nurse or health and environment co- ordinator

23. 23  Run over five days  Five key outcomes for this training programme: –Understand key concepts and principles of HCWM –Understand all aspects of cradle to grave management of all nine health care waste streams –Understand the organisation and reporting for health care waste –To plan training and awareness activities –Able to conduct basic monitoring for non-conformances against the Code of Practice

24. 24 CONCLUSION  Formative and evaluative research results consistently indicated the importance of an integrated approach to the development of training  Two levels of training required: –Generic multi-disciplinary, taught by supervisors in wards and departments; and –Training for HCW Officers Reinforce skills, procedures and positive attitudes. Do not only address knowledge gaps.